AGA Clinical Practice Update on Evaluation and Management of Belching, Abdominal Bloating, and Distention: Expert Review

DescriptionBelching, bloating, and abdominal distention are all highly prevalent gastrointestinal symptoms and account for some of the most common reasons for patient visits to outpatient gastroenterology practices. These symptoms are often debilitating, affecting patients' quality of life, and contributing to work absenteeism. Belching and bloating differ in their pathophysiology, diagnosis, and management, and there is limited evidence available for their various treatments. Therefore, the purpose of this American Gastroenterological Association (AGA) Clinical Practice Update is to provide best practice advice based on both controlled trials and observational data for clinicians covering clinical features, diagnostics, and management considerations that include dietary, gut-directed behavioral, and drug therapies.MethodsThis Expert Review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These best practice advice statements were drawn from a review of the published literature based on clinical trials, the more robust observational studies, and from expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations.Best Practice Advice StatementsBest Practice Advice 1Clinical history and physical examination findings and impedance pH monitoring can help to differentiate between gastric and supragastric belching.Best Practice Advice 2Treatment options for supragastric belching may include brain–gut behavioral therapies, either separately or in combination, such as cognitive behavioral therapy, diaphragmatic breathing, speech therapy, and central neuromodulators.Best Practice Advice 3Rome IV criteria should be used to diagnose primary abdominal bloating and distention.Best Practice Advice 4Carbohydrate enzyme deficiencies may be ruled out with dietary restriction and/or breath testing. In a small subset of at-risk patients, small bowel aspiration and glucose- or lactulose-based hydrogen breath testing may be used to evaluate for small intestinal bacterial overgrowth.Best Practice Advice 5Serologic testing may rule out celiac disease in patients with bloating and, if serologies are positive, a small bowel biopsy should be done to confirm the diagnosis. A gastroenterology dietitian should be part of the multidisciplinary approach to care for patients with celiac disease and nonceliac gluten sensitivity.Best Practice Advice 6Abdominal imaging and upper endoscopy should be ordered in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only.Best Practice Advice 7Gastric emptying studies should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present. Whole gut motility and radiopaque transit studies should not be ordered unless other additional and treatment-refractory lower gastrointestinal symptoms exist to warrant testing for neuromyopathic disorders.Best Practice Advice 8In patients with abdominal bloating and distention thought to be related to constipation or difficult evacuation, anorectal physiology testing is suggested to rule out a pelvic floor disorder.Best Practice Advice 9When dietary modifications are needed (eg, low–fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet), a gastroenterology dietitian should preferably monitor treatment.Best Practice Advice 10Probiotics should not be used to treat abdominal bloating and distention.Best Practice Advice 11Biofeedback therapy may be effective for bloating and distention when a pelvic floor disorder is identified.Best Practice Advice 12Central neuromodulators (eg, antidepressants) are used to treat bloating and abdominal distention by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities.Best Practice Advice 13Medications used to treat constipation should be considered for treating bloating if constipation symptoms are present.Best Practice Advice 14Psychological therapies, such as hypnotherapy, cognitive behavioral therapy, and other brain–gut behavior therapies may be used to treat patients with bloating and distention.Best Practice 15Diaphragmatic breathing and central neuromodulators are used to treat abdominophrenic dyssynergia. Belching, bloating, and abdominal distention are all highly prevalent gastrointestinal symptoms and account for some of the most common reasons for patient visits to outpatient gastroenterology practices. These symptoms are often debilitating, affecting patients' quality of life, and contributing to work absenteeism. Belching and bloating differ in their pathophysiology, diagnosis, and management, and there is limited evidence available for their various treatments. Therefore, the purpose of this American Gastroenterological Association (AGA) Clinical Practice Update is to provide best practice advice based on both controlled trials and observational data for clinicians covering clinical features, diagnostics, and management considerations that include dietary, gut-directed behavioral, and drug therapies. This Expert Review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology. These best practice advice statements were drawn from a review of the published literature based on clinical trials, the more robust observational studies, and from expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements Clinical history and physical examination findings and impedance pH monitoring can help to differentiate between gastric and supragastric belching. Treatment options for supragastric belching may include brain–gut behavioral therapies, either separately or in combination, such as cognitive behavioral therapy, diaphragmatic breathing, speech therapy, and central neuromodulators. Rome IV criteria should be used to diagnose primary abdominal bloating and distention. Carbohydrate enzyme deficiencies may be ruled out with dietary restriction and/or breath testing. In a small subset of at-risk patients, small bowel aspiration and glucose- or lactulose-based hydrogen breath testing may be used to evaluate for small intestinal bacterial overgrowth. Serologic testing may rule out celiac disease in patients with bloating and, if serologies are positive, a small bowel biopsy should be done to confirm the diagnosis. A gastroenterology dietitian should be part of the multidisciplinary approach to care for patients with celiac disease and nonceliac gluten sensitivity. Abdominal imaging and upper endoscopy should be ordered in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only. Gastric emptying studies should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present. Whole gut motility and radiopaque transit studies should not be ordered unless other additional and treatment-refractory lower gastrointestinal symptoms exist to warrant testing for neuromyopathic disorders. In patients with abdominal bloating and distention thought to be related to constipation or difficult evacuation, anorectal physiology testing is suggested to rule out a pelvic floor disorder. When dietary modifications are needed (eg, low–fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet), a gastroenterology dietitian should preferably monitor treatment. Probiotics should not be used to treat abdominal bloating and distention. Biofeedback therapy may be effective for bloating and distention when a pelvic floor disorder is identified. Central neuromodulators (eg, antidepressants) are used to treat bloating and abdominal distention by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities. Medications used to treat constipation should be considered for treating bloating if constipation symptoms are present. Psychological therapies, such as hypnotherapy, cognitive behavioral therapy, and other brain–gut behavior therapies may be used to treat patients with bloating and distention. Diaphragmatic breathing and central neuromodulators are used to treat abdominophrenic dyssynergia. This American Gastroenterological Association Clinical Practice Update and best practice advice statements describe the definition, clinical features, and treatment for the 3 common symptoms of belching, abdominal bloating, and abdominal distention. When these symptoms are frequent or severe enough to impair daily activities, they are categorized as disorders of gut–brain interaction (DGBIs).1Drossman D.A. Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV.Gastroenterology. 2016; 1501282–1279Abstract Full Text Full Text PDF PubMed Scopus (1414) Google Scholar The clinical advice herein is evidence-based when data were available, but when insufficient data were available, level 5 evidence is provided on the basis of expert opinion and is empirically based on observational data and expert consensus of the authors. These symptoms are highly prevalent, possibly affecting patient quality of life (QOL), work productivity, and visits to emergency and outpatient services.2Sperber A.D. Bangdiwala S.I. Drossman D.A. et al.Worldwide prevalence and burden of functional gastrointestinal disorders, results of Rome Foundation global study.Gastroenterology. 2021; 160: 99-114Abstract Full Text Full Text PDF PubMed Scopus (835) Google Scholar, 3Drossman D.A. Li Z. Andruzzi E. et al.US householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact.Dig Dis Sci. 1993; 38: 1569-1580Crossref PubMed Scopus (1972) Google Scholar, 4Peery A.F. Crockett S.D. Murphy C.C. et al.Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018.Gastroenterology. 2019; 156: 254-272Abstract Full Text Full Text PDF PubMed Scopus (904) Google Scholar Limited information is available for gastroenterologists to find expert advice on diagnosing and managing these DGBI symptoms, as we lack robust evidence because much of the existing data are single-centered and, at times, controversial. Few studies address the pathophysiology or risk factors of belching and bloating, and their treatment options remain suboptimal. Furthermore, these disorders overlap with other common DGBIs, and their mechanisms involve both centrally mediated and peripheral processes. In this Expert Review, we separate belching from bloating and distention, given their differing locations, pathophysiology, and pathways for diagnosis and treatment. Rome IV defines belching as an audible escape of air from the esophagus or the stomach into the pharynx. It is considered a disorder and is referred to as "excessive belching" when it is bothersome enough to disrupt the patient's usual activities and occurs more than 3 days per week.5Stanghellini V. Chan F.K. Hasler W.L. et al.Gastroduodenal disorders.Gastroenterology. 2016; 150: 1380-1392Abstract Full Text Full Text PDF PubMed Scopus (913) Google Scholar Belching can occur in otherwise healthy individuals. It also may occur with other disorders, including gastroesophageal reflux disease (GERD), functional dyspepsia (FD), gastroparesis (GP), pregnancy, and psychological symptoms, such as anxiety.6Bredenoord A.J. Weusten B.L. Timmer R. et al.Air swallowing, belching, and reflux in patients with gastroesophageal reflux disease.Am J Gastroenterol. 2006; 101: 1721-1726Crossref PubMed Scopus (59) Google Scholar, 7Piessevaux H. De Winter B. Louis E. et al.Dyspeptic symptoms in the general population: a factor and cluster analysis of symptom groupings.Neurogastroenterol Motil. 2009; 21: 378-388Crossref PubMed Scopus (141) Google Scholar, 8Koukias N. Woodland P. Yazaki E. et al.Supragastric belching: prevalence and association with gastroesophageal reflux disease and esophageal hypomotility.J Neurogastroenterol Motil. 2015; 21: 398-403Crossref PubMed Scopus (49) Google Scholar It has been reported in up to 50% of patients with GERD.9Jeong S.O. Lee J.S. Lee T.H. et al.Characteristics of symptomatic belching in patients with belching disorder and patients who exhibit gastroesophageal reflux disease with belching.J Neurogastroenterol Motil. 2021; 27: 231-239Crossref PubMed Google Scholar,10Hemmink G.J. Bredenoord A.J. Weusten B.L. et al.Supragastric belching in patients with reflux symptoms.Am J Gastroenterol. 2009; 104: 1992-1997Crossref PubMed Scopus (60) Google Scholar Structural causes of belching include hiatal and paraesophageal hernias and, in patients post Nissen fundoplication, an impaired gastric accommodation can lead to symptoms of belching and dyspepsia.11Pauwels A. Boecxstaens V. Broers C. et al.Severely impaired gastric accommodation is a hallmark of post-Nissen functional dyspepsia symptoms.Neurogastroenterol Motil. 2017; 29e13063Crossref Scopus (14) Google Scholar Belching is subdivided into supragastric belching from the esophagus and gastric belching from the stomach. Supragastric belching occurs in up to 3.4% of patients with upper gastrointestinal (GI) symptoms and is more commonly associated with anxiety.8Koukias N. Woodland P. Yazaki E. et al.Supragastric belching: prevalence and association with gastroesophageal reflux disease and esophageal hypomotility.J Neurogastroenterol Motil. 2015; 21: 398-403Crossref PubMed Scopus (49) Google Scholar In a global population-based study of more than 73,000 adults, the overall prevalence of Rome IV belching disorders was 1%.2Sperber A.D. Bangdiwala S.I. Drossman D.A. et al.Worldwide prevalence and burden of functional gastrointestinal disorders, results of Rome Foundation global study.Gastroenterology. 2021; 160: 99-114Abstract Full Text Full Text PDF PubMed Scopus (835) Google Scholar Belching is different from aerophagia. With aerophagia, excessive swallowing of air increases intragastric and intestinal gas. This leads to symptoms of bloating, distention, and, less often, belching.12Hemmink G.J.M. Weusten B.L.A.M. Bredenoord A.J. et al.Aerophagia: excessive air swallowing demonstrated by esophageal impedance monitoring.Clin Gastroenterol Hepatol. 2009; 7: 1127-1129Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Note that in aerophagia, excess air moves to the intestines and colon, therefore, the symptom of flatulence is reported commonly, with bloating as a main manifestation rather than excessive belching alone.6Bredenoord A.J. Weusten B.L. Timmer R. et al.Air swallowing, belching, and reflux in patients with gastroesophageal reflux disease.Am J Gastroenterol. 2006; 101: 1721-1726Crossref PubMed Scopus (59) Google Scholar High-resolution esophageal manometry, if combined with impedance monitoring and impedance pH monitoring, differentiates gastric and supragastric belching and aerophagia. In gastric belching, spontaneous transient relaxation of the lower esophageal sphincter is followed by air transport from the stomach through the esophagus. Gastric belching may be clinically associated with GERD.9Jeong S.O. Lee J.S. Lee T.H. et al.Characteristics of symptomatic belching in patients with belching disorder and patients who exhibit gastroesophageal reflux disease with belching.J Neurogastroenterol Motil. 2021; 27: 231-239Crossref PubMed Google Scholar Then, the upper esophageal sphincter (UES) relaxes and the air is expelled orally.13Dent J. Holloway R.H. Toouli J. et al.Mechanisms of lower oesophageal sphincter incompetence in patients with symptomatic gastrooesophageal reflux.Gut. 1988; 29: 1020-1028Crossref PubMed Scopus (572) Google Scholar Conversely, in aerophagia, air enters into the esophagus through swallowing, leading to the opening of the UES. Then, as the air clears the esophagus via peristalsis, the lower esophageal sphincter relaxes and the air enters the stomach6Bredenoord A.J. Weusten B.L. Timmer R. et al.Air swallowing, belching, and reflux in patients with gastroesophageal reflux disease.Am J Gastroenterol. 2006; 101: 1721-1726Crossref PubMed Scopus (59) Google Scholar (Figure 1A and B). In contrast, supragastric belching involves 2 separate mechanisms—the air-suction method and the air-injection method.14Kessing B.F. Bredenox A.J. Smout A.J.P.M. The pathophysiology, diagnosis and treatment of excessive belching symptoms.Am J Gastroenterol. 2014; 109: 1196-1203Crossref PubMed Scopus (60) Google Scholar The air-suction method differs from aerophagia and gastric belching, as the air flows through a pressure gradient resulting from UES relaxation. The UES relaxation occurs before the influx of air into the esophagus, in contrast with gastric belching, where the relaxation is a late event. Unlike aerophagia, the supragastric air flow occurs more quickly and is independent of esophageal peristalsis (Figures 2A and B and 3A and B). The air-injection method initiates the influx of air into the upper esophagus by means of elevated pharyngeal pressure. This may occur by means of contraction of the base of the tongue rather than a peristaltic contraction of the pharynx, and is not followed by an esophageal peristaltic wave. This latter mechanism is more akin to deliberate belching or burping in healthy individuals and is a learned behavior.Figure 3(A) The impedance pH image on left shows swallowing of air into the esophagus then stomach (see orange arrow on left image) followed by a supragastric belch (thick arrow) then an acid reflux episode follows (blue arrow shows pH < 4.0). (B) Line tracing on right image shows the swallow episode (blue arrow) seen with swallowing of air.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The biopsychosocial history should attend to psychosocial triggering factors, including anxiety, life events, and conditioned responses to stressors of physical symptoms. Notably, supragastric belching stops during sleep, distraction, or when the patient speaks.15Karamanolis G. Triantafyllou K. Tsiamoulos Z. et al.Effect of sleep on excessive belching: a 24-hour impedance-pH study.J Clin Gastroenterol. 2010; 44: 332-334Crossref PubMed Scopus (26) Google Scholar,16Bredenoord A.J. Weusten B.L. Timmer R. et al.Psychological factors affect the frequency of belching in patients with aerophagia.Am J Gastroenterol. 2006; 101: 2777-2781Crossref PubMed Scopus (56) Google Scholar This provides evidence that psychological factors modulate the occurrence and frequency of supragastric belching, which may be responsive to brain–gut behavioral therapies (BGBTs), such as cognitive behavioral therapy (CBT). Belching may be conditioned to reduce the bloating sensation via air release, thereby reducing gastric wall tension. Surprisingly, supragastric belching is less common in children than gastric belching when a GERD association is present.17Masui D. Nikaki K. Sawada A. et al.Belching in children: prevalence and association with gastroesophageal reflux disease.Neurogastroenterol Motil. 2022; 34e14194Crossref PubMed Scopus (4) Google Scholar Therefore, behavioral conditioning occurs later in life, as seen with supragastric belching. Clinicians should first communicate the definition and pathophysiology of gastric and supragastric belching to the patient to establish an understanding and to implement collaborative treatment. Impedance monitoring has helped educate patients, similar to biofeedback therapy for pelvic floor disorders, by objectively demonstrating their physical symptoms as the first step toward treatment when belching is a behavioral disorder and not a consequence of reflux. In belching disorder due to supragastric belching, the reflux episodes are typically nonacidic, which may explain the lack of response to proton pump inhibitors. Recent studies suggested that supragastric belching before reflux activity does not respond to proton pump inhibitor therapy, but supragastric belching after the reflux episodes does.9Jeong S.O. Lee J.S. Lee T.H. et al.Characteristics of symptomatic belching in patients with belching disorder and patients who exhibit gastroesophageal reflux disease with belching.J Neurogastroenterol Motil. 2021; 27: 231-239Crossref PubMed Google Scholar The most effective suggested treatment for supragastric belching has been behavioral strategies, which include helping the patient become aware of the reasons for their symptoms.18Keefer L. Ballou S.K. Drossman D.A. et al.A Rome working team report on brain-gut behavior therapies for disorders of gut-brain interaction.Gastroenterology. 2022; 162: 300-315Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Diaphragmatic breathing (see video: https://romedross.video/3azBfEE) increases vagal tone, inducing relaxation and reducing stress response, and is a treatment option for supragastric belching. In addition, belching associated with GERD symptoms improves when diaphragmatic breathing is combined with proton pump inhibitor therapy.19Ong A.M. Chua L.T. Khor C.J. et al.Diaphragmatic breathing reduces belching and proton pump inhibitor refractory gastroesophageal reflux symptoms.Clin Gastroenterol Hepatol. 2018; 16: 407-416.e2Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Similarly, CBT reduces supragastric belching episodes and esophageal acid exposure, improving QOL.20Glasinovic E. Wynter E. Arguero J. et al.Treatment of supragastric belching with cognitive behavioral therapy improves quality of life and reduces acid gastroesophageal reflux.Am J Gastroenterol. 2018; 113: 539-547Crossref PubMed Scopus (44) Google Scholar BGBTs, such as relaxation training and gut-directed hypnotherapy, combined with central neuromodulators can improve symptom burden and QOL in patients with belching and other functional esophageal symptoms.21Hurtte E. Rogers B.D. Richards C. et al.The clinical value of psycho-gastroenterological interventions for functional esophageal symptoms.Neurogastroenterol Motil. 2022; 34e14315Crossref PubMed Scopus (4) Google Scholar In addition, a dedicated speech therapist can treat supragastric belching effectively,22Hemmink G.J. Ten Cate L. Bredenoord A.J. et al.Speech therapy in patients with excessive supragastric belching—a pilot study.Neurogastroenterol Motil. 2010; 22: 24-28.e2–e3Crossref PubMed Scopus (64) Google Scholar as confirmed by our clinical experience. We do not advocate baclofen for use in supragastric belching alone, but it may be considered to prevent lower esophageal sphincter relaxation in those with gastric belching due to GERD.23Blondeau K. Boecxstaens V. Rommel N. et al.Baclofen improves symptoms and reduces postprandial flow events in patients with rumination and supragastric belching.Clin Gastroenterol Hepatol. 2012; 10: 379-384Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar,24Curcic J. Schwizer A. Kaufman E. et al.Effects of baclofen on the functional anatomy of the oesophago-gastric junction and proximal stomach in healthy volunteers and patients with GERD assessed by magnetic resonance imaging and high-resolution manometry: a randomised controlled double-blind study.Aliment Pharmacol Ther. 2014; 40: 1230-1240PubMed Google Scholar Finally, central neuromodulators may be considered to help reduce psychological distress and raise symptom threshold (eg, bloating) that can trigger belching.25Drossman D.A. Tack J. Ford A.C. et al.Central neuromodulators for functional gastrointestinal disorders (disorders of gut-brain interaction): a Rome Foundation working team report.Gastroenterology. 2018; 154: 1140-1171Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar Because of the different mechanisms of treatment, BGBTs and neuromodulators may be applied in combination (Figure 4). Abdominal bloating is a subjective sensation in any abdominal region experienced by patients as fullness, swelling, trapped gas or gaseousness, or tightness, and is described as "inflamed" in some cultures. In contrast, abdominal distention is a visible increase in abdominal girth, often described as "like a balloon" or "like being pregnant." These conditions have interrelated pathophysiologies, and usually coexisting treatment strategies are hard to separate. The Rome IV criteria define functional bloating and distention as DGBIs with recurrent symptoms of abdominal fullness or pressure or a visible increase in abdominal girth with symptoms at least 1 day per week and active for 3 months, with onset of 6 months, and without a predominance of pain and alteration in bowel habits.5Stanghellini V. Chan F.K. Hasler W.L. et al.Gastroduodenal disorders.Gastroenterology. 2016; 150: 1380-1392Abstract Full Text Full Text PDF PubMed Scopus (913) Google Scholar Rome IV has an abdominal bloating and distention category that is separate from other DGBIs, acknowledging that this can be a primary disorder in some patients. A large global population-based study found a prevalence of functional bloating and distention as high as 3.5% (4.6% in women and 2.4% in men).2Sperber A.D. Bangdiwala S.I. Drossman D.A. et al.Worldwide prevalence and burden of functional gastrointestinal disorders, results of Rome Foundation global study.Gastroenterology. 2021; 160: 99-114Abstract Full Text Full Text PDF PubMed Scopus (835) Google Scholar However, bloating and distention are much more prevalent (>50%) when associated with other DGBIs, including irritable bowel syndrome (IBS), constipation, and FD.26Palsson OS, Simren M, Tack J, et al. Bloating and distension: inherent characteristics of irritable bowel syndrome (IBS) and functional dyspepsia (FD)? Poster presented at: Digestive Disease Week 2022; May 21–24, 2022; San Diego, CA.Google Scholar We will address bloating and abdominal distention as isolated diagnoses and in association with other DGBIs.27Lacy B.E. Cagnemi D. Vazquez-Roque M. Management of chronic abdominal distension and bloating.Clin Gastroenterol Hepatol. 2021; 19: 219-231Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar When the Rome IV diagnostic criteria, as defined above for functional abdominal bloating and distention, are met, the patient should not fulfill criteria for a diagnosis of IBS, functional constipation, functional diarrhea, or FD.5Stanghellini V. Chan F.K. Hasler W.L. et al.Gastroduodenal disorders.Gastroenterology. 2016; 150: 1380-1392Abstract Full Text Full Text PDF PubMed Scopus (913) Google Scholar Because bloating and distention are so prevalent, the Rome IV criteria separate the clinical syndromes from occasional symptoms of bloating and distention. This allows for standardized systematic research and guides the provider to identify which patients should undergo diagnostic testing and treatment.1Drossman D.A. Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV.Gastroenterology. 2016; 1501282–1279Abstract Full Text Full Text PDF PubMed Scopus (1414) Google Scholar,28Drossman D. Ruddy J. Gut Feelings: Disorders of Gut-Brain Interaction and the Patient-Doctor Relationship. Drossman Care, 2021Google Scholar Given the multiple etiologies for bloating and distention, diagnostic testing will depend on an algorithmic approach based on presumptive causes, as discussed below (Figure 5). Carbohydrate enzyme deficiencies (eg, lactase and sucrase), many artificial sweeteners (eg, sugar alcohols and sorbitol), and fructans may lead to symptoms of bloating. They are common in the general population, as the undigested sugars have osmotic effects in the colon due to malabsorption from the failure to digest or absorb lactose or sucrose.29Misselwitz B. Butter M. Verbeke K. et al.Update on lactose malabsorption and intolerance: pathogenesis, diagnosis and clinical management.Gut. 2019; 68: 2080-2091Crossref PubMed Scopus (184) Google Scholar,30Storey D. Lee A. Bornet F. et al.Gastrointestinal tolerance of erythritol and xylitol ingested in a liquid.Eur J Clin Nutr. 2007; 61: 349-354Crossref PubMed Scopus (81) Google Scholar However, not all individuals who malabsorb carbohydrates get symptoms. Those with visceral hypersensitivity (eg, with IBS) are more likely to experience symptoms due to lower sensation thresholds in response to bowel distention.31Wilder-Smith C.H. Materna A. Wermelinger C. et al.Fructose and lactose intolerance and malabsorption testing: the relationship with symptoms in functional gastrointestinal disorders.Aliment Pharmacol Ther. 2013; 37: 1074-1083Crossref PubMed Scopus (124) Google Scholar In the largest cohort of patients with DGBIs, and specifically IBS of all subtypes, evaluated to date, fructose intolerance was more common—seen in 60% of patients—and was higher than lactose intolerance (51%), and its prevalence was similar across all major types of DGBIs, except IBS with constipation (IBS-C).31Wilder-Smith C.H. Materna A. Wermelinger C. et al.Fructose and lactose intolerance and malabsorption testing: the relationship with symptoms in functional gastrointestinal disorders.Alimen